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Therapeutic plasma exchange (TPE) is a therapeutic strategy for severe pathologies of diverse clinical specialties including neurological, rheumatological, renal and hepatic origins, potentially life-threatening, but remarkably not mandatory for critical care.
Several guidelines, such as the Japanese and American Society for Clinical Apheresis (ASFA), set the recommendations for its evidence-based use.
Classically, in Latin America, TPE has been performed in Critical Care Units (ICU), usually without the use of clinical deterioration scores to objectivize ICU needs, increasing costs and reducing the opportunity to get ICU access for real critical care patients.
It is pertinent for emerging economies countries to develop strategies to diminish barriers to access to strategies as TPE.
We expose our experience in a model care of TPE outside ICU.
In our center, Fundación Cardioinfantil in Bogotá, Colombia, we perform TPE in two scenarios according to illness severity: ICU for critical care patients and a TPE room that is used for in hospitalized non critical patients and also for outpatients in intermittent TPE schemes according to ASFA guidelines.
We performed a retrospective analysis over a two-year period from October 2021 to October 2023, in our TPE daycare program.
Over a 2 year period 909 TPE sessions were performed in 106 patients outpatients in the daycare program (women 63,3%, mean (SD) age 34.1(12.1) y.o.) received 208 TPE sessions (23.4%): median (min, max) 6 (1, 25)
The TPE indications according to ASFA were antibody mediated rejection (AMR) in kidney transplant (category I, grade 1 B) (41.3%), pruritus due to hepatobiliary diseases (category III, grade 1C) (11.3%), focal and segmental glomerulosclerosis recurrence in kidney transplant (category I, grade 1B) (1.9%) and AMR of heart transplantation (category III, grade 2C) (9,4%).
Tunneled catheters (94,3%), and arteriovenous fistulas (5,6%) were used.
Replacement fluid was albumin in 87% of sessions (4,6% only FFP, 8,4% mixed with FFP).
As a protocol we use cryoprecipitate when post TPE fibrinogen is lower than 100 mg/dL: 17.7% of sessions require it.
We never use anticoagulation for TPE and no coagulation events were present.
Adverse events were limited to only 5%, with hypotension being the most frequent.
We share our experience in a daycare TPE model for outpatients, our model would result replicable for similar populations worldwide: vg AMR for kidney and heart transplantation based on its high amount of TPE sessions required according to ASFA.
We found that anticoagulation is not mandatory for TPE with adequate surveillance of prescription and care of the circuit (filtration fraction, vascular access function) avoiding collateral effects of anticoagulants, specially for long TPE treatment requirement patients.
Although it was not our aim, we found a reduction of 38% of costs compared to literature cost studies by Terumo (performed in ICU and with heparin). (Comasòlivas N et al, 2019)
We consider based on our experience, that a Daycare TPE model can be a feasible and affordable alternative for TPE patients even more for developing economy countries interested in a wiser use of ICU beds.
Comasòlivas N et al, Value in Health Regional Issues, vol 19, supplement Oct 2019, Pag S 48.